IN THE CIRCUIT/COUNTY COURT OF THE ___________________ JUDICIAL CIRCUIT
IN AND FOR ____________________ COUNTY, FLORIDA
___________________________
__________ CASE NO.______________________
Plaintiff/Petitioner or In the Interest of
vs.
Defendant//Respondent
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
Notice to Applicant: If you qualify for civil indigence, the filing and summons fees are waived; other costs and fees are not waived.
1. I have ______dependents. (Include only those persons you list on your U.S. Income tax return.)
Are you Married?...Yes….No Does your Spouse Work?...Yes….No Annual Spouse Income? $_____________
2. I have a net income of $_______________ paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other _____________.
(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments,
minus deductions required by law and other court-ordered payments such as child support.)
3. I have other income paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other _____________.
(Circle “Yes” and fill in the amount if you have this kind of income, otherwise circle “No”)
Second Job ...................................... Yes $ ________ No
Veterans’ benefits.....................................Yes $ __________ No
Social Security benefits
For you ......................................... Yes $
Workers compensation.............................Yes $ __________ No
________ No
Income from absent family members Yes $ No
For child(ren)................................ ________ Yes $ No
Stocks/bonds............................................Yes $ __________ No
Unemployment compensation .........Yes $ ________ No
Rental income........................................... __________ Yes $ No
Union payments............................... ________ Yes $ No
Dividends or interest................................. __________ Yes $ No
Retirement/pensions........................Yes $ ________ No
Other kinds of income not on the list ........ __________ Yes $ No
Trusts............................................... ________ Yes $ No
Gifts .......................................................... __________ Yes $ No
I understand that I will be required to make payments for costs to the clerk in accordance with §57.082(5), Florida Statutes, as
provided by law,
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although
-
I
--
may
---
agree
-
to
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pay
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more
-
if
-
I
----
choose
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to
-
do
--
so.
4. I have other assets: (Circle “yes” and fill in the value of the property, otherwise circle “No”)
Cash ................................................ Yes $ No Savings account..............................................
Yes $ No
Bank a ccount(s)............................... Yes $ No Stocks/bonds .................................................. Yes $ No
Homestead Real Property*
.............................
Yes $ No
Certificates of deposit or
Money market accounts
................... Yes $ No Motor Vehicle*................................................. Yes $ No
Boats* .......................................... Yes $ No Non-homestead real property/real estate* ...... Yes $ No
Other
assets* Yes $ No
Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset
is_____________________________.
5. I have total liabilities and
debts of
$________ as follows: Motor Vehicle $__________, Home $__________, Boat
$__________, Non-homestead Real Property $__________, Child Support paid direct $__________, Credit Cards
$
__________, Medical Bills $__________, Cost of
medicines (monthly) $______________, Other $__________.
6. I have a private lawyer in this case………___Yes ___No
A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status
under s. 57.082,
F.S. commits a misdemeanor of the first
degree, punishable as provided in s.775.082, F.S. or s. 775.083, F.S. I attest that the information I
have provided on this application is true and accurate to the best of my knowledge.
Signed
on ________________________, 20____.
______________ ___________________________________ Signature of Applicant for Indigent Status
Year of Birth
Last 4 digits of
Driver
License or ID Number Print Full Legal
Name
Email address: Phone Number/s:
Address:
Street,
City, State, Zip Code
This form was completed with the assistance of:
__________________________________________________
Clerk/Deputy Clerk/Other authorized person.
CLERK’S DETERMINATION
Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to s. 57.082,
F.S.
Dated on ______________________, 20 ____. ________________________
Clerk of the Circuit Court
By , Deputy Clerk
APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY A JUDGE BY ASKING FOR A HEARING TIME. THERE IS NO FEE FOR THIS REVIEW.
Sign here if you want the judge to review the clerk’s decision ______________________________________________________________
Updated 5/1/2019
______________________________________
_____________________________________________________________________________________________________________
........ __________
click to sign
signature
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